‘Critical Finding’ in Perinatal Program
In 1975 the Robert Wood Johnston Foundation in Princeton, N.J., awarded a $22-million grant to a program designed to improve services to pregnant women and newborns by testing a new concept: reorganization of prenatal and neonatal care into regional systems in which high-risk pregnancies are identified early and the women referred to give birth at medical centers that offer the best available technology and staff to save the lives of low birth-weight infants.
Eight regions nationwide shared the funds, three of them in the Los Angeles area--administered by UCLA Medical School/Harbor General Hospital, Women’s Hospital in Los Angeles and Charles R. Drew Postgraduate Medical School. The regions established risk assessment systems to uniformly screen all pregnant women, set up referral and transportation systems, and provided outreach to obstetricians and obstetrical nurses.
Under regionalization, pregnant women are carefully monitored by their regular doctors or clinics throughout pregnancy. Delivery is arranged in a hospital providing the level of care she and the baby are expected to need.
Low birth weight, usually caused by prematurity, is the major source of risk to newborns. Low birth-weight babies, defined as weighing less than 2,500 grams (5.5 pounds) at birth, are 40 times more likely to die in the first four weeks of life than heavier babies. Very low birth-weight infants (less than 1,500 grams or 3.3 pounds) are more than 200 times less likely to survive the first month of life.
Increase in Referrals
In the foundation evaluation of the program for the years 1975-1979 released this month (the evaluation was conducted independently by the Johns Hopkins Health Services Research and Development Center), the result of the Perinatal Program was a clear increase in the number of referrals of high-risk births to the hospitals with intensive care for the babies.
Among infants in the very low birth-weight group, the percentage referred for birth in hospitals with appropriate care rose from 47% to almost 60% in the eight regions where the program was operating. The foundation credits the concept of regionalization--which is becoming a trend in other places as well as in the foundation-funded regions--as a “principal contributor” to the 37% drop in U.S. infant mortality during the 1970s.
In addition to saving the lives of premature infants, the goal of the program is to provide the best possible start toward mental and physical health for these infants. The fear was that applying the newest technology to save greater numbers of very premature infants might result in greater numbers of physically or mentally damaged children.
However, the “critical finding” of the evaluation of the foundation program was that this did not happen. Follow-up studies of children at one-year-old found a 16% decline in the number of children with disabilities related to premature birth in the regions; and the greatest decline, 22%, was in the highest risk group, those who weighed 1,500 grams or less at birth.
More Tiny Babies Living
The report cautioned that it is not known whether these children will have other problems associated with low birth weight including learning disabilities or mild neurological defects that often are not revealed until children enter school. Also, during the period of the foundation’s study, few extremely tiny infants, those born weighing less than 1,000 grams, survived. Since 1980, more of these tiny babies are living, and studies of problems they may have as they grow up are continuing.
Among the persistent problems connected with infant health are the need to find ways to prevent prematurity and reaching those groups at highest risk. According to a 1985 study by the Institute of Medicine in Washington, today’s sophisticated techniques for assessing risk during pregnancy miss about a third of the women who eventually deliver a high-risk infant.
And, “. . . the persistent differences in U.S. rates of infant mortality across age, racial, geographic and socioeconomic groups are disturbing,” the report said. The highest risk group are black women, who are twice as likely as white women to give birth to a low birth-weight infant. The infant mortality rate for blacks is twice as high as that for whites. Inability to pay also deters women from good prenatal care that would result in healthier infants as well as identification of problems early in pregnancy. About a fourth of women in the prime childbearing years--18 to 24, when 40% of all U.S. births occur--and about a third of poor women of all ages have no public or private medical insurance at all.
The regional approach to prenatal and neonatal care is seen as very promising as a method of providing universal service that would include disadvantaged women and infants in the high-risk groups.
